Surgery For Proximal Humerus Fractures Research Articles

Percutaneous plate fixation of displaced proximal humerus fractures: Do minimally invasive techniques improve outcomes and reduce complications?

ObjectiveThe aim of this study was to analyze the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) for displaced proximal humerus fractures and elucidate if the percutaneous technique reduces the rate of avascular necrosis (AVN) without jeopardizing fracture reduction. Material and methods118 patients with a displaced proximal humerus fracture were treated with a polyaxial locking-plate through a standardized percutaneous approach. 73 % were women and mean age was 63 years (18–89) with an average follow-up of 51 months (12–256). There were 32 two-part fractures (27 %), 57 three-part fractures (48 %) and 24 four-part fractures (25 %). Shoulder function at the last follow-up, including ROM and ability to perform daily living activities, was objectively evaluated with an adjusted Constant Score (CS). Subjective patient satisfaction was rated with an Visual Analogic Scale from 0 to 10 and the degree of residual pain with a Verbal Rating Scale (VRS). Radiographic analysis at the most recent follow-up evaluated the presence of AVN, degree of residual medial calcar displacement, and the cervicodiaphiseal angle. ResultsForty patients (34 %) had a complication, 25 of them (21 %) requiring further surgery. ROM at the last follow-up was 131° of elevation (40°-180°), 38° of external rotation (SD: 17.7) and internal rotation to L3. Average adjusted Constant Score was 68 (SD: 17.76). Twenty-one patients (18 %) complained of shoulder pain (14 moderate and 7 severe) and seven were not satisfied. Radiographically, 29 patients (25 %) had varus malunion and 17 patients (14 %) showed some degree of AVN. Patients with varus malunion (CS 64.3 versus 69.8, p = 0.16) and AVN (CS 56.9 versus 70.4, p = 0.005) had lower CS. The presence of a varus malunion was directly related to the degree of initial medial calcar displacement (p = 0.001) and deficient calcar reduction at surgery (p = 0.004). AVN was statistically more prevalent when the medial calcar was inadequately reduced (p = 0.01). ConclusionsMIPO surgery for proximal humerus fractures through an anterolateral approach does not reduce the rate of mechanical complications or AVN compared with standard ORIF techniques. Moreover, percutaneous plating may preclude adequate medial calcar reduction, leading to humeral head malunion and a worse clinical outcome.

MELD score predicts short-term outcomes after surgical management of proximal humerus fractures: a matched analysis.

We aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10. This was a retrospective database review. All centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included. Open reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment. Thirty-day complications, mortality, readmission, and reoperation rates were measured. Of the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications. A MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty. Prognostic Level III.

Remimazolam sedation with regional anesthesia in difficult airway due to huge thyroid goiter: A case report.

Remimazolam, a novel benzodiazepine, is known to have less respiratory depression compared to other anesthetic agents, and it also has a reversal agent that can be used in emergency situations. Remimazolam with these characteristics can be usefully utilized in the anesthetic management of patients with difficult airway. A 78-year-old female patient was scheduled proximal humerus fracture surgery. The patient occasionally complained dyspnea and had multiple comorbidities including thyroid goiter, dementia, and delirium. The patient had a large thyroid goiter compressing and deviating the trachea. A short neck with increased circumference was confirmed. A difficult airway was anticipated in the preanesthetic evaluation. Sedation with remimazolam followed by regional anesthesia was performed for the surgery. The surgery was completed without complications. The patient recovered and was discharged on 15th postoperative days. The use of remimazolam for sedation may be an appropriate option in the anesthetic management of patients with difficult airway.

Does interscalene block increase intracranial pressure?

Interscalene brachial plexus (ISB) block is widely used in shoulder and humerus surgeries, especially in patients that have high risk for general anesthesia. Increased intracranial pressure (ICP) is not among the complications of this block because there is no data about this issue in the literature. In this traumatic case report, a patient with headache and with a known meningioma in his right temporo occipital region is gonna have a proximal humerus fracture surgery with ISB block under repetitive optic nerve sheath diameter measurements. The result of this case report can add a unique information to the ISB literature.

Inferior subluxation of humeral head after osteosynthesis for greater tuberosity fracture

BackgroundInferior subluxation of the humeral head is frequently observed immediately after surgery for proximal humerus fractures; however, the incidence and risk factors of inferior subluxation after osteosynthesis for isolated greater tuberosity fractures remain unsolved. Additionally, the postoperative course of inferior subluxation has not been elucidated. The purpose of the present study is to identify the predictors for the occurrence of postoperative inferior subluxation by multivariate analysis and investigate the postoperative shift of inferior subluxation and its effect on surgical outcomes.MethodsWe retrospectively identified 68 patients who underwent surgery for isolated greater tuberosity fractures. The dependent variable was the inferior subluxation at 1 week postoperatively. The explanatory variables were age, sex, affected side of the shoulder, body mass index, history of smoking, local osteoporosis, time period to surgery, axillary nerve injury, inferior subluxation before surgery, fracture dislocation, surgical approach, surgical method, operative time, amount of blood loss, and postoperative drainage. Baseline variables that were statistically significant in the univariate analyses were included in the logistic regression analysis. The patients were further categorized into two groups according to the presence of inferior shoulder subluxation exhibited 1 week postoperatively: patients with inferior subluxation (+ IS group) and patients without inferior subluxation (− IS group). We compared the incidence of postoperative complications between the two groups.ResultsOf 68 patients, 17 (25.0%) had inferior shoulder subluxation observed 1 week postoperatively. Multivariate analysis showed that long operative time was a risk factor for postoperative subluxation (odds ratio = 1.03; P = 0.030). In all cases, inferior subluxation disappeared within 3 months of surgery. No significant difference in complication rate was observed between the + IS and − IS groups.ConclusionsThe present study provides novel information regarding postoperative inferior subluxation of fractures of the greater tuberosity. Inferior subluxation occurred in 25% of patients immediately after surgery. Long operative time contributes to the onset of postoperative inferior subluxation; however, this was temporary in all cases and had no significant effect on the surgical outcomes.Level of Evidence: Level III.

CORR Insights®: Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database.

1Resident, Orthopaedics, Aultman Hospital, Canton, OH, USA N. E. George, Aultman Hospital, Graduate Medical Education, 2600 Sixth Street Southwest, Canton, OH 44710, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database” by Cognetti and colleagues available at: DOI: 10.1097/CORR.0000000000002391. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database.

Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations. In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type. The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling. The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF. The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications. Level III, therapeutic study.

CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

Effect of chronic kidney disease on outcomes following proximal humerus fragility fracture surgery in diabetic patients: A nationwide population-based cohort study.

The proximal humerus fracture (PHF) is the third most common fragility fracture. Diabetes mellitus (DM) and chronic kidney disease (CKD) are both risks for fragility fractures; however, the interplay of DM and CKD makes treatment outcomes unpredictable. This study aimed to investigate and compare early and late outcomes following proximal humerus fracture fixation surgery in diabetic patients with different renal function conditions. DM patients receiving PHF fixation surgery during 1998-2013 were recruited from Taiwan's National Health Insurance Research Database. According to their renal function, patients were divided into three study groups: non-chronic kidney disease (CKD), non-dialysis CKD, and dialysis. Outcomes of interest were early and late perioperative outcomes. Early outcomes included in-hospital newly-onset morbidities. Late outcomes included infection, revision, readmission, and all-cause mortality. This study included a total of 10,850 diabetic patients: 2152 had CKD (non-dialysis CKD group), 196 underwent permanent dialysis (dialysis group), and the remaining 8502 did not have CKD (non-CKD group). During a mean follow-up of 5.56 years, the dialysis group showed the highest risk of overall infection, all-cause revision, readmission, and mortality compared to the non-dialysis CKD group and non-CKD group. Furthermore, subgroup analysis showed that CKD patients had a higher risk of surgical infection following PHF surgery than non-CKD patients in cases with a traffic accident or fewer comorbidities (Charlson Comorbidity Index, CCI <3) (P for interaction: 0.086 and 0.096, respectively). Also, CKD patients had an even higher mortality risk after PHF surgery than non-CKD patients, in females, those living in higher urbanization areas, or with more comorbidities (CCI ≥3) (P for interaction: 0.011, 0.057, and 0.069, respectively). CKD was associated with elevated risks for infection, revision, readmission, and mortality after PHF fixation surgery in diabetic patients. These findings should be taken into consideration when caring for diabetic patients.

Medial cortical positive support: A key factor for the postoperative stability of proximal humerus fractures.

Treatments for proximal humerus fractures (PHFs) often fail to achieve anatomical reduction. The purpose of this study was to evaluate the role of positive medial cortical support (PMCS) in the nonanatomical reduction of PHFs.A retrospective analysis was performed of 78 patients with PHFs who underwent surgery from August 2014 to September 2017 and whose treatments did not achieve anatomical reduction. Based on the results of standard AP radiographs of the shoulders 3, 6, and 12 months after surgery, the patients were divided into PMCS or negative medial cortical support (NMCS) groups. The postsurgical change in head-shaft angle (HSA) between the 2 groups was compared. Shoulder joint function and visual analog scale (VAS) scores of the 2 groups were also compared at the same time.Of the 78 patients analyzed, 37 were in the PMCS group and, 41 in the NMCS group. There was no statistically significant difference in any of the characteristics of the 2 groups (P > .05), or in postsurgical HSA. However, the HSA of the 2 groups had become significantly different (P < .05) 3, 6, and 12 months following surgery. The changes in HSA of the 2 groups were different at various time points (P < .05). One year after surgery, the shoulder function score of the PMCS group was significantly better than that of the NMCS group, as was the VAS score (both P < .05).Patients whose surgery for PHF does not achieve anatomical reduction during surgery can undergo PMCS to achieve improved results, postoperatively. NMCS should be avoided as far as possible.

Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for the Treatment of Proximal Humerus Fractures: A Model-Based Cost-Effectiveness Analysis.

Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures. Parameters and characteristics for a hypothetical cohort of elderly patients with proximal humerus fractures were collected through the literature. A cohort-level Markov decision model was constructed. Incremental cost-effectiveness ratios representing the difference in cost divided by the difference in QALYs were calculated, and scenario, one-way, and probabilistic analysis were conducted. RTSA was associated with lower cost and greater effectiveness compared with HA. The predicted cost difference corresponded to a saving of $99,626 per 100 individuals treated, and the predicted difference in QALY was 16.8 per 100 individuals treated. Results were sensitive to the discount rate, the health-related quality of life assigned to health states, and the cost of the surgical procedures. In probabilistic analysis, 77.1% of iterations were cost-effective at a threshold willingness-to-pay for a QALY of $100,000 US dollars. Findings suggest that RTSA may be a cost-effective alternative to HA for treating elderly patients requiring surgery for proximal humerus fractures. The model and corresponding code are available on request to the corresponding author. Level III.

Pre-operative Hypoalbuminemia Is Associated with Complications Following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients.

Proximal humerus fractures are among the most common presenting fractures to orthopedic surgeons in the USA. Hypoalbuminemia is accepted as a nutrition marker associated with post-operative complications following common orthopedic interventions. Thus, the authors sought to (1) describe the national demographic trends of patients undergoing surgical fixation for proximal humerus fracture and (2) investigate the association between pre-operative hypoalbuminemia, a malnutrition marker, and post-operative complications within 1year of surgical intervention. The PearlDiver Humana Claims Database was queried to identify a nationally representative cohort of patients who underwent surgical intervention for proximal humerus fractures from 2008 to 2015. Demographic and comorbid characteristics were collected. Pearson's χ-squared analysis was used to compare rates of 90-day and 1-year outcomes between hypoalbuminemia (albumin ≤ 3.5mg/dL) and control groups. Multivariate logistic regression was then used to determine the isolated effect that hypoalbuminemia had on post-operative outcomes. Of the 3337 patients identified, 919 (27.5%) had available serum albumin data. Seventy (7.6%) patients had hypoalbuminemia. Hypoalbuminemia was more likely to be associated with post-operative sepsis (7.1% vs. 1.5%, respectively) and pneumonia (15.7% vs. 4.6) compared with controls. Additionally, hypoalbuminemia was associated with increased 90-day rates of discharge to extended care (4.3% vs. 0.8), emergency room visits (38.6% vs. 21.7), and total cost ($24,051.96 ± 24,972.74 vs. $15,429.74 ± 24,492.30). Our study suggests hypoalbuminemia is associated with an increased risk of complications, specifically pneumonia and sepsis, and total health care costs in patients undergoing surgery for proximal humerus fractures. These findings provide insight for individualized patient care that will aid in evaluating the potential risk of surgical complications in an effort to improve outcomes and reduce costs.

Rate of venous thromboembolism after surgical treatment of proximal humerus fractures.

The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established. A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE. 131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245). The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.

Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery.

This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. Retrospective study. University trauma center. We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Evolving trends in surgically managed patients with proximal humerus fracture: are we different after ten years?

New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures. Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications. In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001). Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

Proximal Humeral Nonunion Treated With an Intramedullary Tantalum Cylinder

Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%-80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.

Fractures of the Shoulder Girdle: Editorial Comment

This symposium is a collection of manuscripts dealing with current concepts in the evaluation and management of fractures of the shoulder girdle. Given the relatively high incidence of fractures about the shoulder, particularly those of the proximal humerus, operative techniques and implant technology continue to evolve. The use of locked plating has improved the treatment of proximal humerus fractures in elderly patients with osteoporosis. In patients with osteoporosis or comminuted fractures, however, fixation failure may still occur as the fracture settles during healing, potentially leading to screw penetration within the glenohumeral joint. Strategies to mitigate this complication may include the use of fibular strut allograft within the medullary canal and the use of suture augment within the rotator cuff combined with locked plating while avoiding long locked screws close to the subchondral surface. In general, nonoperative treatment for Neer one-part proximal humerus fractures restores function with minimal or no pain. The use of locked plating for more severe fracture patterns may be associated with worse function compared with its use in less displaced fractures. Further, age may predict function after treatment of displaced proximal humerus fractures less than the initial fracture pattern. Patients can more accurately be advised of their potential function after operative treatment. The incidence of deep venous thrombosis after shoulder surgery appears to be higher than previously thought. The use of aspirin and mechanoprophylaxis after surgery for proximal humerus fractures may provide sufficient treatment to reduce its incidence. Certain proximal humerus fractures are not amenable to plate and screw fixation and are more reliably treated with shoulder arthroplasty. The use of hemiarthroplasty for displaced proximal humerus fractures in the elderly has been associated with variable function but reliable pain relief. It has become clear the healing of the greater tuberosity to the humeral stem represents the most important factor in long-term function. Therefore, the use of a fracture-specific stem over a conventional humeral implant may improve tuberosity healing and, ultimately, patient function. The reverse shoulder prosthesis has been used successfully in the setting of rotator cuff-deficient arthritis. While requiring confirmation, its use for treating fractures appears to be less reliant on greater tuberosity healing for achieving pain relief and overhead elevation. Surgery for select displaced midshaft clavicle fractures has increased given the higher reported incidence of nonunion and symptomatic malunion. As such, implants for clavicle fracture fixation have evolved to lower-profile, precontoured locked plates. The use of precontoured plates may reduce the need for hardware removal, resulting in higher patient satisfaction and clinical results comparable to those of noncontoured conventional plates. Distal clavicle fractures represent a difficult subset of clavicle fractures. The use of precontoured distal clavicle plates with supplemental use of sutures around the coracoid or coracoclavicular screw fixation may more reliably restore function with minimal pain. In the case of operatively treated midshaft clavicle fractures, a plateau in clinical improvement appears to be reached at 1 year after surgery. This may provide a prognostic timeline of recovery for patients who undergo this surgery. Concern over prominent hardware used to treat clavicle fractures has led to further interest in the use of intramedullary devices. The use of the Rockwood pin for displaced midshaft clavicle fractures has been associated with a substantial complication profile, especially wound breakdown, pin prominence, and fracture nonunion. Cautious use of this implant should perhaps be advised. Titanium elastic intramedullary nailing, combined with careful intraoperative fluoroscopy to assess lateral penetration and a more conservative postoperative rehabilitation protocol, may represent an alternative to conventional plate and screw fixation. In general, strict indications for surgery of scapula fractures have remained elusive. The majority of the extraarticular fractures can be treated without surgery without complications while restoring function. The appropriate radiographic evaluation has traditionally included trauma views, which are variable in quality and positioning. The use of CT imaging with three-dimensional reconstruction may allow for more accurate and reproducible measurements of fracture angulation and displacement. Furthermore, surgery for substantially displaced or angulated scapular fractures appears to yield comparable rates of healing and restoration of function to patients managed nonoperatively for less displaced fractures. If surgery is indicated, selective incisions may provide sufficient access to the major fracture lines while minimizing soft tissue dissection. The authors of these articles are to be congratulated for their contributions to our understanding of the diagnosis, operative management, and potential complications of fractures of the shoulder girdle. It is my sincere hope that this symposium will stimulate discussion and raise further questions so as to continue to advance the treatment of shoulder fractures. I hope you enjoy this symposium. Fig. 1 Dr. Konrad I. Gruson is shown.

Thromboembolic Events Are Uncommon After Open Treatment of Proximal Humerus Fractures Using Aspirin and Compression Devices

Thromboembolic phenomena have long been recognized as a major cause of morbidity and mortality in hospitalized patients, especially those undergoing reconstructive surgery. We have been empirically treating patients with aspirin, early ambulation, and mechanoprophylaxis after operative management of proximal humerus fractures. However, we have not established the incidence of postoperative deep vein thrombosis and pulmonary embolism in this population. We determined the incidence of deep vein thrombosis and pulmonary embolism in patients having surgery for displaced proximal humerus fractures treated with our thromboprophylactic regimen. We prospectively followed 50 patients with proximal humerus fractures who underwent fixation with plate osteosynthesis (n = 40) or hemiarthroplasty (n = 10) between August 2005 and December 2008. Deep vein thrombosis prophylaxis consisted of oral enteric-coated aspirin, pneumatic calf compression pumps, and early ambulation in all patients unless medically contraindicated. Color-flow Doppler ultrasound of the affected arm and both lower extremities was performed at a mean of 14 days (range, 7-21 days) postoperatively to evaluate for deep vein thrombosis. All patients clinically suspected to have suffered a pulmonary embolism underwent a CT angiogram. We identified no patients with deep vein thrombosis or pulmonary embolism in this population. Deep vein thrombosis and pulmonary embolism are not uncommon after major reconstructive surgery about the shoulder in untreated patients. Our data suggest these events can be low after surgery for proximal humerus fractures followed by a thromboprophylactic regimen including aspirin, mechanical devices, and early mobilization. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Inferior Subluxation of Humeral of Head after Surgery for Fracture of Proximal Humerus

Purpose: To study the development of inferior shoulder subluxation after surgery for proximal humerus fractures. To analyze the mechanism of development of such subluxation and the association between different types of proximal humerus fractures, quality of reduction achieved and the method of operation performed. Materials and Methods: A retrospective analysis of 45 proximal humerus fractures that were treated by surgery between March 1997 and July 2002 was done. All patients had a minimum of 12 months of postoperative follow up. Preoperative radiographs were classified by the Neer's classification. Different operative treatment methods, post reduction alignment and the degree of postoperative subluxation if present, were analysed. In order to evaluate effect of loss of negative intraarticular pressure, we compared this series with 15 cases of recurrent shoulder dislocation treated by open Bankart operation. Results: 13 patients out of 45 (29%) developed immediate postoperative inferior shoulder subluxation. 3-part fractures of the proximal humerus showed a higher incidence of the same than the 2-part types. The better reduced fractures had lesser rates of subluxation. Open reduction (39%, 11 patients) results in an increased incidence of inferior subluxation than closed methods of reduction (13%, 2 patients). Conclusion: Inferior subluxation of the humeral head after surgery for the proximal humerus fracture can occur and persist till postoperative period of 2 months. Deltoid muscle tone affected by shortening of humeral neck plays an important role. Early active exercise for restoration of deltoid tone may be effective in prevention of inferior subluxation.